Step 1 of 7

14%

Under the Heating Oil Technical Assistance Program (HOTAP), the Pollution Liability Insurance Agency (PLIA) may provide informal site-specific technical consultations to persons conducting independent remedial actions at a hazardous waste site. PLIA may provide such consultations under the authority of the Model Toxics Control Act (MTCA), chapter 70.149 RCW, and its implementing regulations, chapter 374-80 WAC.
After receiving a cleanup report and all other required documentation, PLIA will begin reviewing the information submitted and provide a written opinion letter within 90 days.

PART 1 - ADMINISTRATION

A. Customer Information

The Customer is the person or organization requesting services from PLIA under HOTAP, and is responsible for paying the $350.00 fee. The authority and duty of the Customer are explained in the Agreement.

Name of Customer*

What type of entity is the Customer?*

If the Customer is a “person,” please identify this person and their contact information. If the Customer is an “organization,” then please identify the Project Manager in 1B.

Person

Organization

Customer Mailing Address*

Street AddressAddress Line 2CityStateZip Code

Customer Phone*

Customer Email*

What is the Customer’s involvement at the Site?*

Please check all that apply.

Property owner

Past property owner

Future property owner

Property lessee

Mortgage holder

Consultant

Attorney

Other - please specify.

Other*

If not the current property owner, is the Customer acting as the agent for the property owner?*

Yes

No

If not the current property owner, is the Customer authorized to grant access to the property?*

Yes

No

B. Project Manager Information

PLIA will send this person all official correspondence. Please enter the required information below.

Name*

FirstLast

Title*

Mailing Address*

Street AddressAddress Line 2CityStateZip Code

Phone*

Fax

Email*

C. Project Consultant Information

Is the Customer a consultant?*

Yes

No

Name*

If you answered “NO” and the Customer hired a consultant to conduct the independent remedial action, then enter the required information below.

FirstLast

Title*

Mailing Address*

Street AddressAddress Line 2CityStateZip Code

Phone*

Fax

Email*

Do you want PLIA to contact the Project Consultant?*

Yes

No

D. Property Owner Information

Is the Customer the owner of the property where independent remedial action is being conducted?*

PART 2 - DESCRIPTION OF THE SITE

A. Location of Property where the Releases Occurred (Source Property)

The “source property” is the property where hazardous substances were released into the environment. For example, if heating oil was released from a leaking UST, the source property is the property where the UST was located.

Do you know on which property the releases occurred?*

Yes

No

If you answered “YES,” then please refer to the source property when answering the following questions. If you answered “NO,” then please refer to the property addressed by your remedial action (cleanup) when answering the following questions.

Physical Address*

Please enter the physical address of the property below.

Street AddressAddress Line 2CityStateZip Code

TAX PARCEL #(S):*

B. Identification of Properties affected by the Releases (Affected Properties)

An “affected property” is a property affected by the release of hazardous substances on the source property.
For example, petroleum released from a leaking UST on one property (source property) may migrate through the soil or ground water onto an adjacent property (affected property).

Do any of the releases affect any properties adjacent to the source property?*

Yes

No

Unknown

Address 1*

If you answered “YES,” then please identify below each property that you know has been affected by the releases on the source property. If you need to identify additional properties, please attach additional pages using the file upload at the bottom of this form.

Street AddressAddress Line 2CityStateZip Code

Tax Parcel(s)*

Address 2

Street AddressAddress Line 2CityStateZip Code

Tax Parcel(s)

Address 3

Street AddressAddress Line 2CityStateZip Code

Tax Parcel(s)

Address 4

Street AddressAddress Line 2CityStateZip Code

Tax Parcel(s)

C. Identification of Public Right-of-Ways affected by the Releases

Do any of the releases affect any public right-of-ways (e.g., streets)?*

Yes

No

Unknown

If you answered “YES” above, please specify below.*

D. Description of Release(s) at the Site

Source of Release(s). To the extent known, please describe the source(s) of the release(s).*

Attach additional pages if necessary using file upload at the bottom of this form.

Circumstances of Release(s). To the extent known, please describe below the circumstances of the release(s).*

Attach additional pages if necessary using file upload at the bottom of this form.

Circumstances of Release Discovery. To the extent known, please describe below the circumstances of the discovery of the release(s).*

Attach additional pages if necessary using file upload at the bottom of this form.

Drinking Water

Does any of the contamination at the Site pose a threat or potential threat to an existing drinking water source (ground water or surface water)?*

Yes

No

Unknown

What type of drinking water system is threatened by the contamination? Please check all that apply.*

Single Family

Public Drinking Water Supply

Is the contamination located within or upstream of a 10-year wellhead protection area?*

PART 5 - DESCRIPTION OF INDEPENDENT REMEDIAL ACTIONS AT THE SITE

A. Scope of Remedial Actions

Do you plan to characterize and address all of the contamination at the Site, including any contamination located on affected adjacent properties, as part of the HOTAP project?*

Yes

No

Unknown

If you answered “NO” above, please describe below the scope of the HOTAP project, including the contamination (properties, portions of a property, media and/or hazardous substances) that you DO NOT plan on characterizing and/or addressing as part of the HOTAP project.*

Please attach additional pages if necessary using the file upload at the bottom of this form.

B. Status of Remedial Actions

Please check all that apply.

INITIAL RESPONSE (UST ONLY)*

Planned

Ongoing

Completed

Not Applicable

INTERIM ACTION*

Planned

Ongoing

Completed

Not Applicable

REMEDIAL INVESTIGATION*

Planned

Ongoing

Completed

Not Applicable

FEASIBILITY STUDY*

Planned

Ongoing

Completed

Not Applicable

CLEANUP ACTION*

Planned

Ongoing

Completed

Not Applicable

C. Documentation of Remedial Actions

Remedial Actions

Please list below all known remedial action plans or reports produced for the site, including:
• The title of the plan or report,
• The author (e.g. consulting firm) of the plan or report,
• The date the plan or report was produced,
• Whether the plan or report has been submitted to PLIA,
• The date the plan or report was submitted to PLIA.

PART 6 - TERMS OF AGREEMENT

1. Introduction

As resources permit, the Pollution Liability Insurance Agency (PLIA) will provide advice and technical assistance to the owners and operators of active or abandoned heating oil tanks if contamination resulting from a release is suspected. Advice and technical assistance provided may include:

Observation of sampling and testing, site assessment or other appropriate assessment activities scheduled by the tank owner.

Review of cleanup plans and reports.

Interpretation of the results of testing and/or assessments(s); and

An opinion letter from PLIA to the heating oil tank owner regarding the results of testing
and/or assessment(s).

2. Procedures

a. The heating oil tank owner or operator selects a service provider to perform sampling and testing, site assessment or other appropriate assessments, and site remediation. The tank owner or operator enters into an agreement with the service provider regarding scope or extent of work and fees for services. The tank owner is responsible for payment of all costs associated with soil sampling, site assessment, and remediation.
b. For your convenience, you can view a listing of some of the Service Providers available to perform heating oil tank related services. This list is not an endorsement of the service providers, or a warranty of their work performance.
c. Advice and assistance will be provided only if sampling and testing as well as assessment are performed in accordance with the substantive requirements of MTCA, chapter 70.105D RCW, and its implementing regulations, chapter 173-340 WAC (collectively “substantive requirements of MTCA”). Upon completion of sampling and testing, the original copy of the results of all testing must be forwarded to PLIA for review and evaluation. A copy of the service provider's field notes must also be forwarded to PLIA.
d. If testing and assessment activities have been completed prior to the tank owner requesting advice and assistance, PLIA will consider providing a review and evaluation of the data. PLIA will consider how recently the testing and assessment was completed and will consider the methods of testing and assessment prior to agreeing to review and evaluate the results.
e. Upon completion of review and evaluation, PLIA will provide an opinion letter informing the heating oil tank owner of the results of review and assessment of data. All opinion letters are based on an analysis of the remedial action in accordance with the substantive require- ments of MTCA. A Site is defined as any area where a particle of contamination has come to be located. A Property is defined as the parcel with property boundaries. The opinion letter from PLIA to the tank owner will provide one of the following opinions: Property Further Action or Property No Further Action; or Site Further Action or Site No Further Action.

Property Further Action Opinion Letter - PLIA has determined that further remedial action is necessary at the Property to clean up contamination associated with the Site and has determined that further remedial action is also necessary elsewhere at the Site.

Property No Further Action Opinion Letter - PLIA has determined that no further remedial action is necessary at the Property to clean up contamination associated with the Site and has determined that further remedial action is still necessary elsewhere at the Site.

Site Further Action Opinion Letter - PLIA has determined that further remedial action is necessary to clean up contamination at the Site.

Site No Further Action Opinion letter - PLIA has determined that no further remedial action is necessary to clean up contamination at the Site.

3. Fee

PLIA is authorized to collect a fee to cover the costs incurred in providing advice and assistance. Costs incurred may include travel costs and expenses associated with monitoring site assessment, review of reports and analyses, and preparation of written opinions and conclusions. The fee must be paid in full prior to PLIA issuing its report of review and assessment of data.
The fee for the Heating Oil Technical Assistance Program is $350.00.

4. Liability

The state of Washington and/or the Pollution Liability Insurance Agency accepts no liability, nor portion of liability, from the heating oil tank owner or operator.
The state of Washington, PLIA, and its officers and employees are immune from all liability, and no cause of action arises from any act or omission in providing, or failing to provide, advice, opinion, conclusion, or assistance under this program.

Terms of Agreement*

I understand and agree to the terms of this Agreement as specified above.

PART 7 - STATEMENT AND SIGNATURE

A. Statement and Signature

Upon submitting this form, you will be directed to an e-signature page, attesting and affirming that you understand and agree to the Terms of this Agreement, and that the information contained in this application is true and accurate to the best of your knowledge.